Basic Information
Provider Information | |||||||||
NPI: | 1699775049 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BON SECOURS COTTAGE NURSING CARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 77000 | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482772000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5864474171 | ||||||||
FaxNumber: | 5864474180 | ||||||||
Practice Location | |||||||||
Address1: | 26001 JEFFERSON AVE | ||||||||
Address2: |   | ||||||||
City: | ST CLAIR SHORES | ||||||||
State: | MI | ||||||||
PostalCode: | 480812309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5864474171 | ||||||||
FaxNumber: | 5864474180 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2005 | ||||||||
LastUpdateDate: | 08/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNTER | ||||||||
AuthorizedOfficialFirstName: | CATHY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 5864474161 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X |   |   | Y |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   |
ID Information
ID | Type | State | Issuer | Description | 601689102 | 05 | MI |   | MEDICAID | 504011 | 01 | MI | STATE LICENSE | OTHER |